How does sleeve gastrectomy impact long-term eating-related symptoms, distress, and behavior? A cross-sectional study using the BODY-Q patient-reported outcome measures.

BACKGROUND: Patients undergoing sleeve gastrectomy (SG) experience transformative changes in eating-related experiences that include eating-related symptoms, emotions, and habits. Long-term assessment of these endpoints with rigorous patient-reported outcome measures (PROMs) is limited. We assessed patients undergoing SG with the Body-Q Eating Module PROMs. METHODS: All patients evaluated at the Emory Bariatric Center were given the Body-Q Eating Modules questionnaire at preoperative/postoperative clinic visits. Rasch scores and prevalence of relevant endpoints were assessed across six time-points of interest: preoperatively, post-operative months 0-6, 7-12, 12-24, 24-36, and over 36. Student's t-test and Chi-square test were used for analysis. RESULTS: Overall, 1,352 questionnaires were completed pre-operatively and 493 postoperatively. Survey compliance was 81%. Compared to the pre-operative group, the post-operative group had lower BMI (39.7 vs. 46.4, p < 0.001) and higher age (46.3 vs. 44.9, p = 0.019). Beginning one year after SG, patients experience more frequent eating-related pain, nausea and constipation compared to pre-operative baseline (p < 0.05). They also more frequently experience eating-related regurgitation and dumping syndrome-related symptoms beginning post-operative year two (p < 0.05). In the first year after SG, patients more rarely feel eating-related embarrassment, guilt, and disappointment compared to pre-operative baseline (p < 0.05). These improvements disappear one year after SG, after which patients more frequently experience feeling out of control, unhappy, like a failure, disappointed, and guilty (p < 0.05). In the first year after SG, patients experience an increased frequency in positive eating behaviors (ate healthy foods, showed self-control, stopped before full; (p < 0.05). Only two eating-related behavior improvements persist long-term: feeling in control and eating the right amount (p < 0.05). CONCLUSIONS: Patients undergoing SG may experience more frequent eating-related symptoms, distress, and behavior in the long-term. These findings can enhance the pre-operative informed consent and guide development of a more tailored approach to postoperative clinical management such as more frequent visits with the dietician.

A New Community-to-Hospital Specialist Otology Pathway Using Telemedicine: A Pilot Study of 50 Patients.

INTRODUCTION: Pathway innovation using smartphone otoscopy and tablet-based audiometry technologies to deliver ear and hearing services via trained audiologists may improve efficiency of the service. An ENT-integrated-community-ear service (ENTICES-combining community audiology management, remote ENT review and novel technologies) was piloted. We aimed to assess the efficiency and safety of ENTICES. METHOD: ENTICES was a community-based and audiologist-led pathway. Patients with otological symptoms were self-referred to this service. Smartphone otoscopy and tablet-based audiograms were performed. Two otologists reviewed all decisions made in the community by audiologists based on video-otoscopy, hearing tests and chart reviews. Data on the first 50 consecutive new patients attending either consultant-led hospital otology clinics (HOC), audiologist-led hospital advanced audiology diagnostics (AAD) or ENTICES clinics were collected between 1 August 2021 and 31 December 2021. Data were collected through chart reviews and questionnaires to compare the three pathways with respect to efficiency, patient satisfaction, technology utility and safety. RESULTS: No audiology-led ENTICES decisions were amended by hospital otologists following remote review. Remote review of video-otoscopy with history was sufficient for a diagnosis in 80% of cases. Adding hearing tests and standardised history increased the diagnostic yield to 98%. Patient satisfaction scores showed 100% service recommendation. The cost per patient, per visit, was £83.36, £99.07 and £69.72 for AAD, HOC or ENTICES, respectively. CONCLUSION: ENTICES provides a safe ear and hearing service that patients rated highly. Thirty-two per cent of hospital otology patients were eligible for this service. For those patients, ENTICES is 20% more cost-effective and can reduce the number of clinic visits by up to 60% compared with HOC.

An Emerging Role for Enhancer RNAs in Brain Disorders.

Noncoding DNA undergoes widespread context-dependent transcription to produce noncoding RNAs. In recent decades, tremendous advances in genomics and transcriptomics have revealed important regulatory roles for noncoding DNA elements and the RNAs that they produce. Enhancers are one such element that are well-established drivers of gene expression changes in response to a variety of factors such as external stimuli, cellular responses, developmental cues, and disease states. They are known to act at long distances, interact with multiple target gene loci simultaneously, synergize with other enhancers, and associate with dynamic chromatin architectures to form a complex regulatory network. Recent advances in enhancer biology have revealed that upon activation, enhancers transcribe long noncoding RNAs, known as enhancer RNAs (eRNAs), that have been shown to play important roles in enhancer-mediated gene regulation and chromatin-modifying activities. In the brain, enhancer dysregulation and eRNA transcription has been reported in numerous disorders from acute injuries to chronic neurodegeneration. Because this is an emerging area, a comprehensive understanding of eRNA function has not yet been achieved in brain disorders; however, the findings to date have illuminated a role for eRNAs in activity-driven gene expression and phenotypic outcomes. In this review, we highlight the breadth of the current literature on eRNA biology in brain health and disease and discuss the challenges as well as focus areas and strategies for future in-depth research on eRNAs in brain health and disease.

UK national survey on surgical gowning for tonsillectomy.

OBJECTIVE: Tonsillectomy is a common procedure performed nationally. The personal protective equipment and surgical gowning practices used during this procedure vary widely. We compiled a survey of ENT specialists to gain a national opinion about gowning in tonsillectomy with the aim of determining whether we could make it more environmentally friendly whilst maintaining the highest safety standards. METHOD: We developed a nine-question survey that was piloted prior to final implementation. The questionnaire was sent to senior registrars and consultant otolaryngologists in the UK. RESULTS: The survey was completed by a total of 63 ENT specialists. It was found that 82.54 per cent of clinicians would consider wearing a reusable gown that would be sterilised between each procedure. CONCLUSION: Our survey suggests most ENT clinicians would consider using a more environmentally friendly surgical gown and some may even consider wearing no gown at all, although many are understandably concerned about the transmission of infection or blood splatter.

Clinical diagnosis and management of multiple cerebral ring-enhancing lesions-study of 50 patients at a tertiary healthcare center.

AIM OF THE STUDY: Multiple ring-enhancing lesions are commonly experienced group of brain pathologies which we come across in day-to-day practice. Clinical symptoms in these lesions are quite non-specific, and hence, it is difficult to reach a final diagnosis. However, these lesions have a varied group of differential diagnosis and it is sometimes difficult to have an accurate diagnosis on conventional MRI. This article was written with the objective of discussing the demographical study and etiology, clinical diagnosis and management for these patients. MATERIALS AND METHODS: It is a prospective study carried out at the Department of Neurosurgery, Dr. D Y Patil Medical College and Hospital, Pune, from September 2019 to August 2022 and included 50 patients who presented to us multiple ring-enhancing brain lesions. RESULTS: In our study, 50 patients between age (1-70 years) with multiple ring-enhancing lesions were analyzed. Majority of the patients were between age group 30-39 years. Males (76%) were majority in our study than females (24%). Most common pathology was primary neoplasm (glioma) and metastasis, followed by nine patients of pyogenic abscess and tuberculosis each. Neurocysticercosis was seen in eight patients and three patients were diagnosed with CNS lymphoma. Most of our patients presented with headache (38 patients) and a subset of patients had associated seizures (28 patients). Two patients with primary neoplasm were diagnosed to have WHO grade 3 glioma and seven patients were diagnosed to have WHO grade 4 glioma. Glioblastoma multiforme presented as multifocal and multicentric lesions. Among the patients with primary neoplasm, three patients underwent stereotactic biopsy for diagnosis and the rest of seven patients underwent maximum safe resection followed by chemotherapy and radiotherapy. Ten patients were diagnosed with metastatic lesions, among them six patients underwent stereotactic biopsy for histopathological diagnosis and immunohistochemistry, and rest of the patients were managed on the basis of the primary lesion. Five patients were immune-compromised, among them two patients presented with abscess and three patients presented with primary neoplastic lesion. Thirty-six patients underwent biopsy, among them seven patients underwent frameless, seven patients underwent frame stereotactic biopsy, and the rest 22 patients underwent excision biopsy. CONCLUSION: Multiple ring-enhancing lesions of brain pose a challenge in terms of achieving an accurate diagnosis and planning further treatment. It is of utmost importance to have a diagnosis in mind based on radiological investigations, so that surgical intervention can be planned accordingly be it by invasive or minimal invasive techniques. An idea toward the diagnosis also helps in prognosticating these patients which could avoid costly whole-body scans and unnecessary surgical intervention.

Validation of portable in-clinic video-based gait analysis for prosthesis users.

Despite the common focus of gait in rehabilitation, there are few tools that allow quantitatively characterizing gait in the clinic. We recently described an algorithm, trained on a large dataset from our clinical gait analysis laboratory, which produces accurate cycle-by-cycle estimates of spatiotemporal gait parameters including step timing and walking velocity. Here, we demonstrate this system generalizes well to clinical care with a validation study on prosthetic users seen in therapy and outpatient clinics. Specifically, estimated walking velocity was similar to annotated 10-m walking velocities, and cadence and foot contact times closely mirrored our wearable sensor measurements. Additionally, we found that a 2D keypoint detector pretrained on largely able-bodied individuals struggles to localize prosthetic joints, particularly for those individuals with more proximal or bilateral amputations, but after training a prosthetic-specific joint detector video-based gait analysis also works on these individuals. Further work is required to validate the other outputs from our algorithm including sagittal plane joint angles and step length. Code for the gait transformer and the trained weights are available at https://github.com/peabody124/GaitTransformer .

Evidence of the Immunomodulatory Effects of Selective Serotonin Reuptake Inhibitors in Patients With Depression Through a Systematic Review.

Depression is a common illness, affecting >264 million people worldwide. According to the literature, depression patients have baseline subclinical inflammation. The immunomodulatory effects of antidepressants, such as selective serotonin reuptake inhibitors (SSRIs), are largely unclear and poorly understood. Using evidence-based medicine, this study aimed to determine the immunomodulatory effects of SSRIs by assessing changes in immunomodulatory markers following SSRI treatment. Using the PubMed website, a literature search was conducted with various terminologies related to the treatment of depression and various markers of inflammation. Out of 387 retrieved articles, after critical appraisal and screening based on inclusion and exclusion criteria, 17 were selected. Qualitative synthesis and quantitative analysis were carried out. RevMan 5 software was used to synthesize and evaluate the data. Microsoft Word and Excel (Microsoft Corporation, Redmond, Washington, United States) were used for generating tables and figures. We extracted data from a total of 839 patients in 17 studies. A highly significant reduction in interleukins-6 (IL-6) (standardised mean difference (SMD) = 1.32 (95% confidence interval (CI): 0.58, 2.06), Z = 3.48, P = 0.0005), a significant reduction in tumor necrosis factor-alpha (TNF-α) (SMD = 1.29 (95% CI: 0.19, 2.39), Z = 2.30, P = 0.02) but no change in overall C-reactive protein (CRP) (SMD = 0.40 (95% CI: -0.26, 1.07), Z = 1.19, P = 0.23) levels were observed by using the random-effects model. There was substantial heterogeneity found between the studies. SSRIs have an immunomodulatory effect in patients with depression by significantly reducing the peripheral pro-inflammatory cytokine markers of IL-6 and TNF-α, which may contribute to ameliorating the response to antidepressant drug treatment. In contrast, no effects of SSRIs on acute-phase protein CRP were found.

Pituitary Apoplexy Presenting with Isolated Third Nerve Palsy: A Rare Case Report.

A 46-year-old female came to neurosurgery outpatient department with sudden onset of drooping of RE upper eyelid and restriction of movements in adduction, depression and elevation in right eye. Patient was a known case of diabetes mellitus whose blood sugar levels were deranged. On examination, patient was diagnosed pituitary macroadenoma. Patient was treated for her uncontrolled diabetes mellitus following which she had underwent transsphenoidal pituitary macroadenoma removal. On treatment, patient's ptosis had subsided and restriction of movement has resolved.

Translational symmetry in convolutions with localized kernels causes an implicit bias toward high frequency adversarial examples.

Adversarial attacks are still a significant challenge for neural networks. Recent efforts have shown that adversarial perturbations typically contain high-frequency features, but the root cause of this phenomenon remains unknown. Inspired by theoretical work on linear convolutional models, we hypothesize that translational symmetry in convolutional operations together with localized kernels implicitly bias the learning of high-frequency features, and that this is one of the main causes of high frequency adversarial examples. To test this hypothesis, we analyzed the impact of different choices of linear and non-linear architectures on the implicit bias of the learned features and adversarial perturbations, in spatial and frequency domains. We find that, independently of the training dataset, convolutional operations have higher frequency adversarial attacks compared to other architectural parameterizations, and that this phenomenon is exacerbated with stronger locality of the kernel (kernel size) end depth of the model. The explanation for the kernel size dependence involves the Fourier Uncertainty Principle: a spatially-limited filter (local kernel in the space domain) cannot also be frequency-limited (local in the frequency domain). Using larger convolution kernel sizes or avoiding convolutions (e.g., by using Vision Transformers or MLP-style architectures) significantly reduces this high-frequency bias. Looking forward, our work strongly suggests that understanding and controlling the implicit bias of architectures will be essential for achieving adversarial robustness.

A multimodal deep learning tool for detection of junctional ectopic tachycardia in children with congenital heart disease.

Background: Junctional ectopic tachycardia (JET) is a prevalent life-threatening arrhythmia in children with congenital heart disease. It has a marked resemblance to normal sinus rhythm, often leading to delay in diagnosis and management. Objective: The study sought to develop a novel multimodal automated arrhythmia detection tool that outperforms existing JET detection tools. Methods: This is a cohort study performed on 40 patients with congenital heart disease at Texas Children's Hospital. Electrocardiogram and central venous pressure waveform data produced by bedside monitors are captured by the Sickbay platform. Convolutional neural networks (CNNs) were trained to classify each heartbeat as either normal sinus rhythm or JET based only on raw electrocardiogram signals. Results: Our best model improved the area under the curve from 0.948 to 0.952 and the true positive rate at 5% false positive rate from 71.8% to 80.6%. Using a 3-model ensemble further improved the area under the curve to 0.953 and the true positive rate at 5% false positive rate to 85.2%. Results on a subset of data show that adding central venous pressure can significantly improve area under the receiver-operating characteristic curve from 0.646 to 0.825. Conclusion: This study validates the efficacy of deep neural networks to notably improve JET detection accuracy. We have built a performant and reliable model that can be used to create a bedside alarm that diagnoses JET, allowing for precise diagnosis of this life-threatening postoperative arrhythmia and prompt intervention. Future validation of the model in a larger cohort is needed.

Motion Contrast, Phase Gradient, and Simultaneous OCT Images Assist in the Interpretation of Dark-Field Images in Eyes with Retinal Pathology.

The cellular-level visualization of retinal microstructures such as blood vessel wall components, not available with other imaging modalities, is provided with unprecedented details by dark-field imaging configurations; however, the interpretation of such images alone is sometimes difficult since multiple structural disturbances may be present in the same time. Particularly in eyes with retinal pathology, microstructures may appear in high-resolution retinal images with a wide range of sizes, sharpnesses, and brightnesses. In this paper we show that motion contrast and phase gradient imaging modalities, as well as the simultaneous acquisition of depth-resolved optical coherence tomography (OCT) images, provide additional insight to help understand the retinal neural and vascular structures seen in dark-field images and may enable improved diagnostic and treatment plans.

Smad4 restricts injury-provoked biliary proliferation and carcinogenesis.

Cholangiocarcinoma (CCA) is a deadly and heterogeneous type of cancer characterized by a spectrum of epidemiologic associations as well as genetic and epigenetic alterations. We seek to understand how these features inter-relate in the earliest phase of cancer development and through the course of disease progression. For this, we studied murine models of liver injury integrating the most commonly occurring gene mutations of CCA - including Kras, Tp53, Arid1a and Smad4 - as well as murine hepatobiliary cancer models and derived primary cell lines based on these mutations. Among commonly mutated genes in CCA, we found that Smad4 functions uniquely to restrict reactive cholangiocyte expansion to liver injury through restraint of the proliferative response. Inactivation of Smad4 accelerates carcinogenesis, provoking pre-neoplastic biliary lesions and CCA development in an injury setting. Expression analyses of Smad4-perturbed reactive cholangiocytes and CCA lines demonstrated shared enriched pathways, including cell-cycle regulation, MYC signaling and oxidative phosphorylation, suggesting that Smad4 may act via these mechanisms to regulate cholangiocyte proliferation and progression to CCA. Overall, we showed that TGFß/SMAD4 signaling serves as a critical barrier restraining cholangiocyte expansion and malignant transformation in states of biliary injury.

Disruption of neural periodicity predicts clinical response after deep brain stimulation for obsessive-compulsive disorder.

Recent advances in surgical neuromodulation have enabled chronic and continuous intracranial monitoring during everyday life. We used this opportunity to identify neural predictors of clinical state in 12 individuals with treatment-resistant obsessive-compulsive disorder (OCD) receiving deep brain stimulation (DBS) therapy ( NCT05915741 ). We developed our neurobehavioral models based on continuous neural recordings in the region of the ventral striatum in an initial cohort of five patients and tested and validated them in a held-out cohort of seven additional patients. Before DBS activation, in the most symptomatic state, theta/alpha (9 Hz) power evidenced a prominent circadian pattern and a high degree of predictability. In patients with persistent symptoms (non-responders), predictability of the neural data remained consistently high. On the other hand, in patients who improved symptomatically (responders), predictability of the neural data was significantly diminished. This neural feature accurately classified clinical status even in patients with limited duration recordings, indicating generalizability that could facilitate therapeutic decision-making.

Laryngectomy in Young Patients: A Case Series and Review of the Literature.

Background and objective The peak incidence of laryngeal cancer is seen in individuals aged over 65 years, with very few patients under 50 years developing advanced laryngeal cancer necessitating laryngectomy. Apart from often delayed diagnosis, this younger cohort faces a unique set of challenges related to fertility preservation, lower recruitment to clinical trials, and significant psychological impact. In light of this, this case series aimed to examine the various characteristics of patients below the age of 50 years undergoing total laryngectomy. Methods We reviewed departmental records at the University College Hospital London, spanning a period of 10 years, to identify patients who underwent total laryngectomy under the age of 50 years. Results The group comprised a total of nine patients over the age of 10 years: five males and four females. Six (66.7%) patients were smokers, and two (22.2%) had human papillomavirus (HPV)-16-positive disease. These patients underwent a variety of operative techniques. The length of postoperative inpatient stay varied greatly, ranging from five to 44 days (mean: 23 days). Conclusion There appears to be a lower prevalence of classical risk factors in our younger cohort undergoing total laryngectomy, as well as a reduced incidence of HPV-16 and a higher proportion of females. We also bring to light the significant psychological impact that these younger patients face and highlight the key learning point that clinicians must be vigilant in investigating younger patients with suspicious symptoms, even in the absence of obvious risk factors. Although further research is needed, this series is unique in that currently there are no other papers outlining laryngectomies in a patient group aged below 50 years.

Laryngectomy in Elderly Patients: A Case Series and Review of the Literature.

Background and objective Patients over the age of 75 years make up 20% of the head and neck cancer population, which is a relatively under-represented patient cohort in clinical literature. To our knowledge, there are no studies evaluating the outcomes of laryngectomy in patients aged over 75 years, which prompted us to present this unique series. Methods We reviewed departmental records at the University College Hospital, London over a 10-year period, and identified a total of 18 patients over the age of 75 years who underwent total laryngectomy for squamous cell carcinoma. We evaluated the demographic, clinical, and histopathologic features and outcomes for each patient. Results The age of the cohort ranged from 75 to 90 years, with a mean age of 79.8 years. All patients had a Charlson Comorbidity Index (CCI) score of 3 or more (due to age), with a mean of 4.7, and a maximum score of 8 for two patients. Length of inpatient stay varied significantly, ranging from 20 to 149 days, with a mean of 46 days. We identified 14 patients who underwent laryngectomy prior to September 2017, in whom the five-year survival was 21.4%. The three-year survival rate for all patients was 22.2%. In bivariate analysis, advanced age at surgery positively correlated with increased length of hospital admission and increased incidence of complications, although these results were not statistically significant (p<0.05). Conclusions Our study highlights the significance of the impact of age and comorbidities on postoperative outcomes and sheds light on the unique challenges faced by an ageing population. Careful consideration must be made in terms of appropriate patient selection, and clinicians must offer a robust and tailored approach to elderly care.